Hemodialysis facility star rating affects mortality in chronic hemodialysis patients: a longitudinal observational cohort study

Many countries have their own hemodialysis (HD) quality assurance programs and star rating systems for HD facilities. However, the effects of HD quality assurance programs on patient mortality are not well understood. Therefore, in the present study, the effects of the Korean HD facility star rating on patient mortality in maintenance HD patients were evaluated. Methods: This longitudinal, observational cohort study included 35,271 patients receiving HD treatment from 741 facilities. The fivestar ratings of HD facilities were determined based on HD quality assessment data from 2015, which includes 12 quality measures in structural, procedural, and outcome domains. The patients were grouped into high (three to five stars) and low (one or two stars) groups based on HD facility star rating. Cox proportional hazards model was used to evaluate the effects of star rating on patient mortality during the mean follow-up duration of 3 years. Results: The patient ratio between high and low HD facility star rating groups was 82.0% vs. 18.0%. The patients in the low star rating group showed lower single-pool Kt/V and higher calcium and phosphorus levels compared with subjects in the high star rating group. After adjusting for sociodemographic and clinical parameters, the HD facility star rating independently increased the mortality risk (hazard ratio, 1.11; 95% confidence interval, 1.04–1.18; p = 0.002). Conclusion: The HD facilities with low star rating showed higher patient mortality.

Clinical outcomes among hemodialysis patients with atrial fibrillation: a Korean nationwide population-based study

Background@#The number of patients requiring dialysis is increasing worldwide, and the atrial fibrillation and atrial flutter (AF) prevalence among hemodialysis (HD) patients is higher than in the general population. There have been no studies of Korean AF patients undergoing HD that investigated how AF affects outcomes, such as all-cause mortality, hospitalization, and stroke events. We conducted a large-scale retrospective cohort study with data from the National Health Insurance System to determine how AF affects these outcomes. @*Methods@#In 2013, the Health Insurance Review and Assessment service, a Korean national health insurance scheme, collected data from 21,839 HD patients to evaluate the adequacy of dialysis centers. All-cause mortality, hospitalization, and stroke events were compared between patients with and without AF. Sub-analyses compared these outcomes between AF patients receiving warfarin and those not receiving warfarin. @*Results@#Cox regression analysis found that AF was a significant risk factor for death from any cause (hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.222–1.506; p < 0.001), hospitalization (HR, 1.323; 95% CI, 1.225–1.430; p < 0.001), and hemorrhagic stroke (HR, 1.500; 95% CI, 1.050–2.141; p = 0.026). AF was not significantly associated with an increased risk of ischemic stroke. The use of warfarin was significantly associated with hemorrhagic stroke incidence (HR, 1.593; 95% CI, 1.075–2.360; p = 0.020), while there was no significant correlation between warfarin treatment and all-cause mortality, hospitalization, and ischemic stroke. @*Conclusion@#This cohort study of Korean dialysis patients showed that AF was a risk factor for multiple outcomes among HD patients.

Clinical outcomes among hemodialysis patients with atrial fibrillation: a Korean nationwide population-based study

Background@#The number of patients requiring dialysis is increasing worldwide, and the atrial fibrillation and atrial flutter (AF) prevalence among hemodialysis (HD) patients is higher than in the general population. There have been no studies of Korean AF patients undergoing HD that investigated how AF affects outcomes, such as all-cause mortality, hospitalization, and stroke events. We conducted a large-scale retrospective cohort study with data from the National Health Insurance System to determine how AF affects these outcomes. @*Methods@#In 2013, the Health Insurance Review and Assessment service, a Korean national health insurance scheme, collected data from 21,839 HD patients to evaluate the adequacy of dialysis centers. All-cause mortality, hospitalization, and stroke events were compared between patients with and without AF. Sub-analyses compared these outcomes between AF patients receiving warfarin and those not receiving warfarin. @*Results@#Cox regression analysis found that AF was a significant risk factor for death from any cause (hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.222–1.506; p < 0.001), hospitalization (HR, 1.323; 95% CI, 1.225–1.430; p < 0.001), and hemorrhagic stroke (HR, 1.500; 95% CI, 1.050–2.141; p = 0.026). AF was not significantly associated with an increased risk of ischemic stroke. The use of warfarin was significantly associated with hemorrhagic stroke incidence (HR, 1.593; 95% CI, 1.075–2.360; p = 0.020), while there was no significant correlation between warfarin treatment and all-cause mortality, hospitalization, and ischemic stroke. @*Conclusion@#This cohort study of Korean dialysis patients showed that AF was a risk factor for multiple outcomes among HD patients.

Impact of chronic kidney disease on mortality: A nationwide cohort study

BACKGROUND: Mortality is higher in patients with chronic kidney disease (CKD) than in the general population, but little information is available on CKD-related mortality that is representative of the Korean population. Our objective was to investigate mortality risk in Korean patients with CKD. METHODS: We identified patients with incident CKD who had not undergone dialysis or kidney transplantation between January 1, 2003 and December 31, 2007 in Korea using the database of the Korean National Health Insurance Service-National Sample Cohort, and stratified the population into the following three groups: group 1 (n = 1,473), controls; group 2 (n = 2,212), patients with diabetes or hypertension, but without CKD; and group 3 (n = 2,212), patients with CKD. We then monitored them for all-cause mortality until December 2013. RESULTS: A total of 1,473 patients were included in this analysis. During the follow-up period, 941 patients in group 3 died (134 deaths/1,000 person-years) compared with 550 deaths in the group 2 (34 deaths/1,000 person-years) and 459 deaths in group 1 (30 deaths/1,000 person-years). The rate ratio for mortality rate was 4.5, and the hazard ratio for mortality was 4.88 (95% confidence interval [CI], 4.36–5.47, P < 0.001) in patients in group 3 compared with age- and sex-matched controls (group 1). The rate ratio for mortality rate was 4.0, and the hazard ratio for mortality was 4.36 (95% CI, 3.92–4.85, P < 0.001) in patients in group 3 compared with patients in group 2. CONCLUSION: In this nationally representative sample cohort, excess mortality was observed in Korean patients with incident CKD.

Fracture risk in chronic kidney disease: A Korean population-based cohort study

BACKGROUND: Chronic kidney disease (CKD)-mineral and bone disorder (MBD) and fracture risk are both closely related to declining renal function. Controlling hyperphosphatemia with phosphate binders is a basic principle of CKD-MBD treatment. The aim of this study was to identify differences in fracture risk between pre-dialysis CKD patients and end-stage renal disease (ESRD) on dialysis, and to evaluate the effects of phosphate binders on fracture risk in ESRD patients. METHODS: Data from a total of 89,533 CKD patients comprising CKD diagnosis, dialysis, fracture history, and phosphate binder prescription history from 2012 to 2016 were retrieved from the Health Insurance Review and Assessment Service Database. Multivariate Cox regression analyses were performed to identify whether dialysis or phosphate binders were associated with an increased fracture risk. RESULTS: Overall, the rate of fractures in pre-dialysis CKD patients was 74 per 1,000 patient-years, while that in dialysis patients was 84 per 1,000 patient-years. The risk of fracture in ESRD patients was higher than pre-dialysis CKD patients (hazard ratio, 1.16; 95% confidence interval, 1.12–1.21; P < 0.001) after adjusting for confounding variables. In addition, the fracture risk in patients who were not taking phosphate binders was 20.0% higher compared to ESRD patients taking phosphate binders. CONCLUSION: Fractures were more prevalent in ESRD patients on dialysis than pre-dialysis CKD patients. Use of phosphate binders was associated with a lower fracture risk in ESRD patients.

Factors that Affect the Adherence to ADHD Medications during a Treatment Continuation Period in Children and Adolescents: A Nationwide Retrospective Cohort Study Using Korean Health Insurance Data from 2007 to 2011

OBJECTIVE: Several factors, such as male gender, older age, type of insurance, comorbid conditions, and medication type, have been associated with attention-deficit/hyperactivity disorder (ADHD) medication adherence rates, but the results have been inconsistent. We analyzed data to answer several questions: 1) How old were patients who first refilled their treatment medications used primarily for ADHD, regardless of the medication type? 2) What socio-demographic factors are associated with medication adherence? 3) What medical conditions, such as medication type and comorbid diagnosis, influence adherence? METHODS: We analyzed National Health Insurance data, which comprised continuously enrolled Korean National Medical Insurance children (6–18 years) with at least 2 ADHD prescription claims (January 2008–December 2011). The persistence of use regarding the days of continuous therapy without a 30-day gap were measured continuously and dichotomously. Adherence, using a medication possession ratio (MPR), was measured dichotomously (80% cut-off). RESULTS: The cumulative incidence of index cases that initiated medication refills for ADHD treatment during the 4 year period was 0.85%. The patients who exhibited a MPR greater than 80 comprised approximately 66%. The medication type, high school age groups, physician speciality, treatment at a private clinic, and comorbid conditions were associated with medication adherence during continuous treatment using a multivariate analysis. CONCLUSION: A better understanding of ADHD treatment patterns may lead to initiatives targeted at the improvement of treatment adherence and persistence. Other factors, including the severity, family history, costs, type of comorbidities, and switching patterns, will be analyzed in future studies.

Differences in Utilization Patterns among Medications in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: a 36-Month Retrospective Study Using the Korean Health Insurance Review and Assessment Claims Database

We evaluated the differences in utilization patterns including persistence and adherence among medications in children and adolescents with attention deficit hyperactivity disorder (ADHD). The current study was performed using data from the Korean Health Insurance Review and Assessment claims database from January 1, 2009 to December 31, 2013. Our study sample consisted of 10,343 children and adolescents with ADHD who were not given their newly prescribed medication in 360 days before the initial claim in 2010. Data were followed up from the initiation of treatment with ADHD medications in 2010 to December 31, 2013. Discontinuation rates for 4 ADHD medications in our sample ranged from 97.7% for immediate-release methylphenidate to 99.4% for atomoxetine using refill gap more than 30 days and from 56.7% for immediate-release methylphenidate to 62.3% for extended-release methylphenidate using refill gap more than 60 days. In the number of discontinued, we found significant differences among medications using refill gap more than 30 days. Among 4 ADHD medications, extended-release methylphenidate and atomoxetine had more days than immediate-release methylphenidate and osmotic-controlled oral delivery system methylphenidate. In logistic regression analyses, extended-release methylphenidate, osmotic-controlled oral delivery system methylphenidate, and atomoxetine showed less discontinuation compared to immediate-release methylphenidate group when a refill gap more than 30 days was used. In logistic regression analysis of adherence, we could not find any differences among 4 medication types. We suggest that the utilization patterns should be assessed regularly in order to improve future outcomes in children and adolescents with ADHD.

Differences in Utilization Patterns among Medications in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: a 36-Month Retrospective Study Using the Korean Health Insurance Review and Assessment Claims Database

We evaluated the differences in utilization patterns including persistence and adherence among medications in children and adolescents with attention deficit hyperactivity disorder (ADHD). The current study was performed using data from the Korean Health Insurance Review and Assessment claims database from January 1, 2009 to December 31, 2013. Our study sample consisted of 10,343 children and adolescents with ADHD who were not given their newly prescribed medication in 360 days before the initial claim in 2010. Data were followed up from the initiation of treatment with ADHD medications in 2010 to December 31, 2013. Discontinuation rates for 4 ADHD medications in our sample ranged from 97.7% for immediate-release methylphenidate to 99.4% for atomoxetine using refill gap more than 30 days and from 56.7% for immediate-release methylphenidate to 62.3% for extended-release methylphenidate using refill gap more than 60 days. In the number of discontinued, we found significant differences among medications using refill gap more than 30 days. Among 4 ADHD medications, extended-release methylphenidate and atomoxetine had more days than immediate-release methylphenidate and osmotic-controlled oral delivery system methylphenidate. In logistic regression analyses, extended-release methylphenidate, osmotic-controlled oral delivery system methylphenidate, and atomoxetine showed less discontinuation compared to immediate-release methylphenidate group when a refill gap more than 30 days was used. In logistic regression analysis of adherence, we could not find any differences among 4 medication types. We suggest that the utilization patterns should be assessed regularly in order to improve future outcomes in children and adolescents with ADHD.

Naturalistic Pharmacotherapy Compliance among Pediatric Patients with Attention Deficit/Hyperactivity Disorder: a Study Based on Three-Year Nationwide Data

We examined short- and long-term medication compliance among youth with attention-deficit hyperactivity disorder (ADHD), using data from the National Health Insurance database in Korea. Of the 5,699,202 6-14-year-old youth in 2008, we chose those with at least 1 medical claim containing an ICD-10 code for diagnosis of ADHD (F90.0) and no prescription for ADHD within the previous 365 days. We tracked the data every 6 months between 2008 and 2011, to determine treatment compliance among newly diagnosed, medicated patients. Further, we checked every 1 month of the 6 months after treatment commencement. Treatment continuity for each patient was calculated by sequentially counting the continuous prescriptions. For measuring compliance, we applied the medication possession ratio (MPR) as 0.6, 0.7, and 0.8, and the gap method as 15- and 30-days' intervals. There were 15,133 subjects; 11,934 (78.86%) were boys. Overall 6-month treatment compliance was 59.0%, 47.3%, 39.9%, 34.1%, 28.6%, and 23.1%. Monthly drop-out rates within the first 6 months were 20.6%, 6.5%, 4.7%, 3.7%, 3.0%, and 2.5%, respectively. When applying MPR more strictly or shorter gap days, treatment compliance lessened. This is the first nationwide report on 36-month treatment compliance of the whole population of 6-14-year-olds with ADHD. We found the beginning of the treatment, especially the first month, to be a critical period in pharmacotherapy. These results also suggest the importance of setting appropriate treatment adherence standards for patients with ADHD, considering the chronic course of ADHD.

Pilot Study on Construction of a Database for In-depth Analysis of Occupant Injury and Vehicle Damage of Domestic Motor Vehicle Crash Accidents

PURPOSE: The purpose of this study is to suggest methods for construction of a database for in-depth analysis of the relationship between occupant injury and vehicle damage in domestic motor vehicle crash accidents through analysis of real examples of real motor vehicle crash accidents. METHODS: Among patients who visited the emergency room of three domestic hospitals due to motor vehicle crash accidents from January 2011 to September 2011, we collected data on patients with an ISS (Injury Severity Score) over 16. In addition, we surveyed the cause of the accident, information on vehicles involved in the accident, the type and amount of damage inflicted on the vehicle, and the severity of injury of the patient. Damage to the vehicle was presented using the CDC (Collision Deformation Classification) code by evaluation of photo-images of the damaged vehicle, and a trauma score was used for evaluation of the severity of the patient's injury. RESULTS: Of 76 cases of motor vehicle accidents, the number of subjects was 87, with an average age of 43.2+/-17.9. Of these, 68(78.2%) subjects were males, 65(74.7%) subjects were drivers, 35(42.2%) subjects had fastened their seat belts, and, in 15(19.7%) cases, the airbag was deployed in the accident. Averages of ISS and RTS (Revised Trauma Score) were 32.3 and 6.6, respectively. Among 45 cases of frontal collision, chest injury was the most common (30,66.7%), and average AIS (Abbreviated Injury Scale) of chest injury was the highest (3.1+/-0.7). Severity of head injury (AIS 1) and mean ISS by PDoF (Principal Direction of Force) showed a significant difference (p<0.001, p=0.003, respectively), and mean ISS between seat belt users and non-users also differed (23.8 vs. 37.5, p=0.002). In addition, the occupant's mean ISS in vehicles whose airbag was deployed was lower (23.7 vs. 33.9), however, no statistically significant difference was observed (p=0.123). CONCLUSION: For analysis of the relationship between occupant injury and vehicle damage in domestic motor vehicle crash accidents, construction of an in-depth database through the national surveillance system for motor vehicle traffic accidents is necessary.

The Explanation of Postoperative Change of Vertebral Rotation and Rib Hump Using 3 Dimensional Finite Element Scoliosis Model / 대한척추외과학회지

STUDY DESIGN: An analytical study using a mathematical 3-D finite element model for thoracic scoliosis. OBJECTIVE: To find the important kinematics and post-operative changes of the spine and rib cage, in the corrective surgery for scoliosis, using the rod derotation method. SUMMARY OF LITERATURE REVIEW: A conventional corrective surgery for scoliosis was performed, based on empirical knowledge, and an increase in the secondary postoperative change in the rib hump, and a shoulder level imbalance, were reported. However, no analytical data exists for the kinematics and optimal correction method. MATERIALS AND METHODS: A mathematical finite element model of a normal spine, including the rib cage, sternum, both clavicles and pelvis, was developed. Using geometric mapping, with standing radiographs and CT images, a 3-D FEM of scoliosis was reconstructed, after translating and rotating the 3-D FEM of a normal spine, with the amounts analyzed from 12 built-in digitized coordinate axes for each vertebral image. With this model, three elements; distraction, translation and derotation, in operative kinematics, were investigated by analyzing the Cobb angle, apical vertebrae axial rotation (AVAR) and thoracic kyphosis. A simulation of a segmental pedicle screw fixation, with rod derotation for scoliosis, was performed. The changes in the Cobb angle, kyphotic angle, AVAR and rib hump were compared after 0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees and 90 degrees rod derotations. RESULTS: In kinematics, the vertebral rod derotation of a major curve, without rod deformation, is less influential in the correction of scoliosis, simply causing an increase in the rib hump. During the simulation, the co-action of distraction and translation, during rod insertion, has a major impact on the decrease in the Cobb angle and in the maintenance of the kyphotic angle. However, after a 30 degrees rod derotation, a decrease in the kyphosis, and increases in the rib hump and AVAR were observed. CONCLUSIONS: The distraction and translation factors were more important in operative kinematics than the rod derotation. With excessive rod derotation, the Cobb angle progressively decreased, but increases in the secondary change in the rib hump and rotation of the apical vertebrae were found.